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E/M with no HPI

B

britbrit852003

Guru
Messages
174
Location
Colorado Springs, CO
I am auditing a new patient visit and there is no HPI or ROS. Can an E/M even be billed with out this info?
Can you please reference a source when answering I need to show a co-worker.
 
No a new patient requires all 3 key components to be met. History cannot be counted unless at a minimum you have a brief HPI. Look in your E&M guidelines for the number of elements for each component level and your code book for the information on number of key components for a new patient encounter.
 
I agree, you do not have a level of service for a new patient without an HPI. The lowest level - a problem focused new patient visit requires
HPI = 1 - 3 elements
ROS - none
PFSH - none
 
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